Vomiting and Malabsorption in Children

Question 1

Types of vomiting

Answer 1

Vomiting with retching
Projectile vomiting
Bilious vomiting
Effortless vomiting

Question 2

Phases and features of these phases of vomiting with retching

Answer 2

Pre-ejection phase

• pallor
• nausea
• tachycardia

Ejection phase

• retch
• vomit

Post-ejection phase

• weakness, pale and limp
• shivering
• lethargy

Question 3

What stimulates vomiting centre?

Answer 3

enteric pathogens 
Intestinal inflammation 
Metabolic derangement 
Infection 
Head injury 
Visual stimuli 
Middle ear stimuli

Question 4

Features of bilious vomiting

Answer 4

Should always ring alarm bells

Due to intestinal obstruction until proven otherwise

Question 5

Causes of bilious vomiting

Answer 5

Intestinal atresia 
Malrotation +/- volvulus 
Intussusception 
Ileus 
Crohn's disease with strictures

Question 6

Investigations of bilious vomiting

Answer 6

Abdominal x-ray
Consider contrast meal
Surgical opinion re exploratory laparotomy

Question 7

Daily, how much fluid enters the duodenum, and how much of this gets to the colon and is lost in faeces?

Answer 7

9L enters duodenum each day
1.5L gets to colon
< 200ml lost in faeces

Question 8

What causes the 600-fold increase in surface area of the small intestine?

Answer 8

Mucosal folds

Villi

Question 9

Essential secretory component of GI tract

Answer 9

Water for fluidity/enzyme transport/absorption
Ions
Defence mechanism against pathogens

Question 10

Features of pyloric stenosis

Answer 10

Babies
4-12 weeks old
Boys > girls 
Projectile non-bilious vomiting 
Weight loss
Dehydration +/- shock

Question 11

Characteristic electrolyte disturbance in pyloric stenosis

Answer 11

Metabolic acidosis
Hypocholoraemia
Hypokalaemia

Question 12

Features of gastro-oesophageal reflux

Answer 12

Movement of gastric contents into the oesophagus - GORD occurs when this causes inflammation
Effortless vomiting
Very common problem in infants
Usually self-limiting and resolves spontaneously

Question 13

Presenting symptoms of gastro-oesophageal reflux/GORD

Answer 13

Gi

• vomiting
• haematemesis

Nutritional

• feeding problems
• failure to thrive

Respiratory

• apnoea
• cough
• wheeze
• chest infections

Neurological
- Sandifer’s syndrome

Question 14

What is Sandifer’s syndrome?

Answer 14

Association of GORD with spastic torticollis and dystonic body movements
Nodding and rotation of the head, neck extension, gurgling sounds, writhing movements of limbs and severe hypotonia have been reported
Causal relation between GORD and neurological manifestations of Sandifer’s syndrome is supported by the resolution of the manifestations on successful treatment of GORD

Question 15

Medical assessment of GORD

Answer 15

History and examination often sufficient
Radiological investigations
- Video fluoroscopy (only if swallowing problems)
- Barium swallow

pH study - gold standard
Oesophageal impedance monitoring
Endoscopy if not resolved in 2 years or severe symptoms

Question 16

What features or GORD can be picked up on radiology?

Answer 16

Dysmotility
Reflux
Gastric emptying
Strictures

Question 17

Treatment of gastro-oesophageal reflux

Answer 17

Feeding advice
Nutritional support
Medical treatment
Surgery

Question 18

Feeding advice for gastro-oesophageal reflux

Answer 18

Feed thickeners e.g. carobel
Appropriateness of foods - texture and amount
Behavioural programme - oral stimulation, removal of aversive stimuli
Feeding position - 45 degrees

Question 19

Nutritional support for gastro-oesophageal reflux

Answer 19

Calorie supplements
Exclusion diet
Nasogastric tube
Gastrotomy

Question 20

Medical treatment of gastro-oesophageal reflux

Answer 20

Feed thickener e.g. gaviscon
Prokinetic drugs
Acid-suppressing drugs

Question 21

Indications for surgery for gastro-oesophageal reflux

Answer 21

Failure of medical treatment

Persistent

• failure to thrive
• aspiration
• oesophagitis

Vomiting without complications is not an indication

Question 22

Features of Nissen Fundoplication

Answer 22

Children with cerebral palsy are more likely to have complications of bloat, dumping and retching after surgery
Successful surgery may unmask more generalised GI motility problems in the child
Post-operative course may be more complicated in children with cerebral palsy

Question 23

Chronic diarrhoea definition

Answer 23

4 or more stools per week

• < 1 week = acute diarrhoea
• 2-4 weeks = persistent diarrhoea
• > 4 weeks = chronic diarrhoea

Question 24

Causes of chronic diarrhoea

Answer 24

Motility disturbance

• toddler’s diarrhoea
• irritable bowel syndrome

Active secretion

• acute infective diarrhoea
• IBD
• secretory

Malabsorption of nutrients

• food allergy
• CF
• coeliac disease
• osmotic

Question 25

Features of osmotic diarrhoea

Answer 25

Movement of water into the bowel to equilibrate osmotic gradient
Usually a feature of malabsorption - enzymatic defect or transport defect
Mechanism of action of lactulose/movicol
Generally accompanied by macroscopic and microscopic intestinal injury
Clinical remission with removal of causative agent

Question 26

Types of carbohydrate malabsorption

Answer 26

Primary lactose malabsorption very rare
Secondary lactose malabsorption e.g. rotavirus infection 
Glucose-galactose malabsorption 
Fructose malabsorption 
Disaccharidases deficiency

Question 27

Causes of fat malabsorption

Answer 27

Pancreatic Disease

• Diarrhoea due to lack of lipase and resultant steatorrhoea
• Classically cystic fibrosis

Hepatobiliary Disease

• Chronic liver disease
• Cholestasis

Question 28

Features of secretory diarrhoea

Answer 28

Classically associated with toxin production from vibrio cholerae and enterotoxigenic E. coli - in cholera, can lose 24L per day
Intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR

Question 29

Features of motility diarrhoea

Answer 29

Classically toddler’s diarrhoea

Other causes - irritable bowel syndrome, congenital hyperthyroidism, chronic intestinal pseudo-obstruction

Question 30

Features of inflammatory diarrhoea

Answer 30

Mixed bag
Malabsorption due to intestinal damage
Secretory effect of cytokines
Accelerated transit time in response to inflammation
Protein exudate across inflamed epithelium

Question 31

Important features of history of a child with diarrhoea

Answer 31

Age at onset 
Abrupt/gradual onset
Family history 
Nocturnal defaecation - suggests organic pathology 
Consider growth and weight gain of child

Question 32

Components of faeces analysis

Answer 32

Appearance
Stool culture
Determination of secretory vs osmotic

Question 33

What percentage of Western population are affected by coeliac disease?

Answer 33

1%

Question 34

Presentation of coeliac disease

Answer 34

Abdominal bloating 
Diarrhoea 
Failure to thrive
Short stature
Constipation 
Tiredness
Dermatitis herpatiformis

Question 35

Susceptible asymptomatic group to coeliac disease

Answer 35

Type 1 DM
Autoimmune thyroid disease
Down syndrome
First degree relatives of people with coeliac disease

Question 36

Screening tests for coeliac disease

Answer 36

Serological screens

• anti-tissue transglutaminase
• anti-endomysial
• concurrent IgA deficiency in 2% may result in false negatives

Gold standard - duodenal biopsy

Genetic testing - HLA DQ2, DQ8

Question 37

ESPCHAN/BSPCHAN Guidelines for coeliac disease

Answer 37

Symptomatic children 
Anti-TTG > 10 times upper limit of normal 
Positive anti-endomysial antibodies 
Normal serum IgA 
HLA DQ2, DQ8 positive 
Diagnose coeliac disease without biopsy

Question 38

Treatment of coeliac disease

Answer 38

Strict gluten-free diet for life - avoid rye, wheat and barley

Gluten must not be removed prior to diagnosis as serological and histological features will resolve

In very young (< 2 years) re-challenge and re-biopsy may be warranted

Increased risk of rare small bowel lymphoma if untreated